OCMA Blog

The federal Affordable Care Act (ACA) included an increase in reimbursement to eligible primary care physicians for specified services provided from January 1, 2013 through December 31, 2014. Payments for services rendered to Medi-Cal patients will be reimbursed at Medicare rates for the two-year period.

However, according to DHCS and CMS policy, total payment for services rendered may not exceed a provider's billed charges. Due to system limitations at the DHCS, providers may be restricted from billing their usual and customary rates on the PM-160 billing form. In most cases, providers have adapted to this restriction by billing at the expected Medi-Cal reimbursement rate for services provided to Child Health and Disability Prevention Program (CHDP) participants. This has created a problem for physicians anticipating the higher reimbursements, as according to DHCS and CMS policy, the providers have been paid at billed charges and are not owed additional ACA reimbursement. As a result, millions of dollars in payments to California physicians have not been released.

CalOptima and other California managed care plans have been working with the DHCS for several months to develop a solution that wouldn't require physicians to re-bill all eligible CHDP claims in order to obtain the increase. At the urging of physician advocacy groups such as CMA, OCMA and other stakeholders, the DHCS has agreed to a workaround that would allow these practices to be paid at the higher rate without the inconvenience of rebilling each claim.

DHCS recently released an online form where providers may attest to their usual and customary rates for CHDP services, allowing the practice to receive the higher reimbursement intended by the ACA rate increase. This attestation must be completed by November 28, 2014. The form may be found online at: http://files.medi-cal.ca.gov/pubsdoco/ACA/articles/acanews_23115_1.asp

DHCS recently announced it intends to make an interim payment on CHDP claims in December, with a true up to occur in 2015.

By Donald Sharps, M.D.
CalOptima Behavioral Health Medical Director

The phrase, “people fear what they do not understand,” is true when dealing with the stigma that surrounds mental illness. In the media, behavioral health is often blamed for irrational behavior and acts of violence. In schools and offices, you can hear name-calling using words like crazy, insane or psycho. A lack of awareness continues to spread this stigma and it can be a barrier for people to get behavioral health services to improve their quality of life.

Just as diabetes is a disease of the pancreas, mental illness is a disease of the brain. People are not their diseases. Be aware and do not label a person as schizophrenic or bipolar. A person can have schizophrenia or a bipolar disorder, just as a person can have diabetes. It is important that people increase their awareness of mental health and wellness to reduce the stigma of mental illness. To accept and cope with having a mental illness is difficult enough. It is even harder when a person feels there is a stigma associated with mental illness. Treatment is available for behavioral health issues and it is possible for people to achieve and maintain recovery.

How has the Affordable Care Act changed the way people access behavioral health services and treatment for mental health disorders?

As of January 1, 2014, the Affordable Care Act (ACA) expanded health care benefits to include behavioral health services. However, many people still do not access services for reasons ranging from lack of awareness, to the fear of being labeled and being treated differently. By reducing the stigma of behavioral health issues, we can assist people in getting the needed treatment that is available to them.
With ACA, Medi-Cal has expanded so that more people are eligible, by providing coverage for people who earn up to 138 percent of the federal poverty level (about $15,800 for an individual). It has also increased coverage among non-elderly adults by extending Medi-Cal eligibility to childless adults and increasing Medi-Cal eligibility for parents who lose access when their income fluctuates and slightly exceeding the poverty level.

The ACA also ensures that all health plans offer a comprehensive package of services, known as essential health benefits, which includes Mental Health and Substance Use Disorder Services.

These Behavioral Health Services are now available to all Medi-Cal members:

Individual and group psychotherapy

Psychological testing to evaluate a mental health condition

Psychiatric consultation and ongoing treatment, that cannot be managed at the primary care level of health care

Members can call the Orange County Mental Health Plan Access Line at 1-800-723-8641 for screening and referral to services. Primary care providers, network providers, community-based organizations and county programs can also call the Access Line. This line is available 24 hours a day, 7 days a week.

To get information regarding the Drug Medi-Cal County Alcohol and Other Drug Program (AOD), call the OC LINKS behavioral health services and referral line at 1-855-OC-LINKS (1-855-625-4657).

PROTECT ACCESS TO CARE IN CALIFORNIA

DON'T PATCH IT, REPEAL IT!

MEDICARE SGR REPEAL AND PAYMENT REFORM: HR 4015/S 2000

Physicians: Call Congress Now! (800) 833-6354 (Takes 2 Min)

UPDATE MARCH 11, 2014:House Republican leaders have scheduled a vote for this week on H.R. 4015, with a repeal of the ACA individual mandate as the funding source. (If the mandate is repealed, the government will spend less on premium subsidies and thus, a substantial cost savings will occur.)

This repeal of the ACA is not an acceptable, viable funding option in the U.S. Senate. Knowing that the ACA repeal will not be accepted, House leaders have scheduled a second vote at the end of March to adopt another nine-month patch.

CMA is urging Congress to find bipartisan funding sources. We are opposing another nine-month patch. CMA is calling upon Congress to Fix Medicare Now!

A long-awaited and hard-fought bill to permanently repeal Medicare's fatally flawed sustainable growth rate (SGR) formula finally is before Congress. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015/S. 2000) offers a fiscally prudent opportunity for lawmakers to repeal the SGR formula and put Medicare on the path toward a stable, 21st-century program that can meet the growing health care needs of the nation's seniors.

This is the most progress Congress has made in a decade. We must seize this opportunity and make a final push to get this bill passed NOW. To sustain the bipartisan momentum, your Congressional representatives need to hear from you.

There are many powerful groups that are pushing back, objecting to Congress' plans for funding the physician payment fix. That's where you come in. To overcome the opposition, Congress needs to hear from a large volume of physicians. Every single physician needs to call and email the California Senators and your Member of Congress NOW!

Congress has a significant opportunity to finally repeal the SGR and enact payment reform. Why?

The cost to repeal the SGR is at an all-time low of $116 billion - down from $238 billion.

Congress has already spent $154 billion over the last decade adopting short-term patches to stop the SGR cuts - more than the total cost to repeal the SGR. It is fiscally irresponsible to adopt another one-year SGR patch. The Wall Street Journal calls the "patches" a sham.

There is a bipartisan, bicameral agreement on legislation to establish a new payment system.

The deadline is March 31, 2014, when the next 24 percent SGR cut occurs.

But reform won't happen unless Congress hears from thousands of physicians!Physicians must call Congress to fix Medicare now!To overcome the partisan funding proposals and the other opposition, Congress needs to hear from a large volume of physicians. Every physician needs to call and email the California Senators and your Member of Congress NOW! Please make as many calls and send as many emails as possible. Every one makes a difference! We are asking physicians to call/email the following individuals:

Your local congressional representative (use your local zip code)

California Senator Barbara Boxer

California Senator Dianne Feinstein

House Republican Whip Kevin McCarthy (zip code 93309)

House Democratic Leader Nancy Pelosi (zip code 94103)

To contact members of Congress:
Call AMA's Grassroots Hotline, (800) 833-6354, to be connected with your members of Congress in Washington. You will be asked to enter your zip code and select your representative. You are also encouraged to call your representatives in their local district offices (click hereto download a current telephone roster).

You may also email your federal legislators via the AMA's "Fix Medicare Now" grassroots website. Utilizing the sample letter provided, it takes no more than two minutes.

Urge Congress to tell their House and Senate leadership to:
1. Protect access to care in California and enact Medicare physician payment reform NOW.
2. The cost to fix the Medicare SGR is at an all-time low and there is bipartisan agreement on the legislation.
3. Use bipartisan funding sources.
4. Oppose another one-year SGR patch.

Ask your patients to help:
AMA has also prepared a flyer that you can use to get your patients involved in the fight to protect Medicare. Distribute the AMA's "Fix Medicare Now" flyer to your patients and ask them to call their representatives, too.

OC In+Care: A newsletter for providers serving people living with HIV/AIDS in Orange County

How does ACA affect patients?

There are three ways in which ACA may affect people living with HIV/AIDS (PLWH/A).

1) ACA will not impact your patient if they:

Would like to keep their current private insurance plan

Have employer-based insurance

Are receiving Ryan White medical care and ineligible for ACA

Are CalOptima (Medi-Cal in Orange County) or Medicare patients

2) ACA offers an opportunity for Individuals living with HIV/AIDS to quality for CalOptima coverage based on Federal Poverty Level (FPL) which is about $15,000 per year for one person.

Individuals who are legal residents with income below 138% FPL.

Patients who are currently on Medical Services Initiative (MSI) will be automatically enrolled into CalOptima for individuals below 138% FPL.

3) ACA requires that your patient purchase insurance and enroll in the health insurance exchange through Covered California if the individual is above 138% of the FPL. Depending on the individual, financial assistance such as: subsidies, health insurance premium payment, and/or waivers may be available.

For patients who do not qualify for private health insurance, Medi-Cal, or will receive services not covered by their current coverage, they may be eligible for the federally-funded Ryan White program. This program offers medical, supportive services, and medication assistance for individuals who have no other source of paying for care services.

Covered California Enrollment Locations- Orange County

AIDS Services Foundation- (949) 809-5781 -Sky Park Circle, Irvine

AltaMed- (877) 462-2582 - S. Bristol Ave., Santa Ana

APAIT Health Center- (714) 636-1349 - Garden Grove Blvd, Garden Grove

Delhi Community Center- (714) 481-9600 - E. Central Ave., Santa Ana

The Center OC- (714) 953-5428 ext. 336- N. Spurgeon St., Santa Ana

Covered California

For patients who are interested in health insurance options other than their current plan, or their income puts them above the 138% FPL, they will have to apply through the health insurance exchange. In California, this is called Covered California.

Multiple locations in Orange County have enrollment workers who can help patients enroll in appropriate health coverage; whether it is into private insurance or Medi-Cal. Individuals can also visit the Covered California website at www.coveredca.com..

Subsidies may be available to patients who have enrolled in a Covered California approved plan.

Office of AIDS-Health Insurance Premium Payment (OA-HIPP)

OA-HIPP is a program for individuals living with HIV/AIDS and need assistance in payments for health insurance premiums. Individuals above 138% FPL who qualify for AIDS Drugs Assistance Program (ADAP), may also qualify to receive assistance with premiums. For more information on OA-HIPP, visit: www.cdph.ca.gov/programs/aids/Pages/tOAHIPPindiv.aspx

Important Reminders

If the patient currently has ADAP or Ryan White coverage, s/he will be screened at their eligibility appointment for all programs s/he may be eligible.

Patients should be reminded to attend their eligibility appointment.

If the patient has a case manager or a care coordinator, they can assist the patient in addressing questions regarding ACA.

Enrollment varies depending on coverage.

If patient is eligible for Medi-Cal, enrollment began October 1, 2013. Coverage will begin January 1, 2014, but patients can apply at any time.

If the patient is above 138% FPL and is eligible for a Qualified Health Plan through Covered California, enrollment began October 1, 2013 and ends March 31, 2014. Open enrollment is between October through December thereafter.

Remind clients to open and read their mail as important information regarding health coverage is being disseminated via mail.

OC In+Care is a project of the Orange County HIV Quality Management Committee. The HIV Quality Management Committee works to increase the quality of Ryan White services. For more information about the committee, please call (714) 834-8711.

If you have feedback or topic suggestions for future newsletters, please contact Mindy He at Mhe@ochca.com

Medi-Cal Resource:

Over the past year, there have been a number of changes for Medi-Cal patients and for the physicians who treat them with more to come in 2014. Be sure to review CMA's new Medi-Cal Survival Toolkit available for free at www.cmanet.org/ces (members only).

BONUS TIP:

The deadline to avoid a 1.5% fee schedule penalty in 2015 is fast approaching. There is still time to report at least one valid individual measure via claims for dates of service in 2013. There are many measures that only need to be reported once per reporting period (January 1 through December 31, 2013) that meet the requirement.

One of the provisions of the ACA requires employers to provide their employees notice of the new state health insurance exchange (Covered California). Regardless of whether or not your practice offers employees health insurance, employers subject to the Fair Labor Standards Act (FLSA) are required to provide notification of purchasing options and subsidies available through the Covered California health exchange by October 1, 2013 (model notices are available at www.marshhealthoptions.com). Generally employers with one or more employees who generate sales of $500,000 or more annually are required to provide the notice. There is one notice for employers who provide their employees with health insurance and one notice for employers who do not provide health insurance to their employees. Since the FLSA applies broadly, most employers are subject to the requirement.

The Patient Protection and Affordable Care Act (PPACA), as amended by the H.R. 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires payments to be increased to the Medicare equivalent for certain primary care services. The increased payments are retroactive for dates of service on or after January 1, 2013, for both fee-for-service and managed care programs.

According to the final rule, physicians must meet the following criteria to be eligible for increased payments:

A physician as defined in 42 Code of Federal Regulations (CFR) 440.50, with a specialty designation of family medicine, general internal medicine, pediatric medicine or a subspecialty within one of the listed specialties.

AND

Meeting at least one of the following qualifications:

o Board certified in a specialty or subspecialty as recognized by the American Board of Medical Specialties, the American Osteopathic Association and the American Board of Physician Specialties.

OR

o At least 60 percent of the services billed to Medi-Cal for the most recently completed calendar year fall within the Evaluation and Management (E&M) or vaccine administration codes covered by the regulation.

Services provided at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are not eligible and will continue to receive their prospective payment system (PPS) rate. Physicians must attest online to be eligible for the increased payments.

The Department of Health Care Services (DHCS) is working with Xerox State Healthcare, LLC, (Xerox) the DHCS Fiscal Intermediary (FI), to make the necessary system changes. Upon complete implementation of the system, DHCS will initiate payment corrections for eligible services provided on or after January 1, 2013. Eligible providers will receive the increased payments for future claims as defined in the Centers for Medicare & Medicaid Services (CMS) Final Rule.

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone

The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

California Leads the Way

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

Protecting Physician Interests

Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

Action Under the Dome

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation, so large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA.

Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA's objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.